Family Practice, 2016, Vol. 33, No. 2, 154–160 doi:10.1093/fampra/cmv106 Advance Access publication 24 January 2016
Health Service Research
Cost-effectiveness of the ‘Walcheren Integrated Care Model’ intervention for community-dwelling frail elderly Wilhelmina M Looman*, Robbert Huijsman, Clazien A M Bouwmans-Frijters, Elly A Stolk and Isabelle N Fabbricotti Institute of Health Policy and Management, Erasmus University Rotterdam, Rotterdam, The Netherlands. *Correspondence to Wilhelmina M Looman, Institute of Health Policy and Management, Erasmus University Rotterdam, PO Box 1738, 3000 DR Rotterdam, The Netherlands; E-mail: [email protected]
Abstract Background. An important aim of integrated care for frail elderly is to generate more costeffective health care. However, empirical research on the cost-effectiveness of integrated care for community-dwelling frail elderly is limited. Objective. This study reports on the cost-effectiveness of the Walcheren Integrated Care Model (WICM) after 12 months from a societal perspective. Methods. The design of this study was quasi-experimental. In total, 184 frail elderly patients from 3 GP practices that implemented the WICM were compared with 193 frail elderly patients of 5 GP practices that provided care as usual. Effects were determined by health-related quality of life (EQ5D questionnaire). Costs were assessed based on questionnaires, GP files, time registrations and reports from multidisciplinary meetings. Average costs and effects were compared using t-tests. The incremental cost-effectiveness ratio (ICER) was calculated, and bootstrap methods were used to determine its reliability. Results. Neither the WICM nor care as usual resulted in a change in health-related quality of life.The average total costs of the WICM were higher than care as usual (17 089 euros versus 15 189 euros). The incremental effects were 0.00, whereas the incremental costs were 1970 euros, indicating an ICER of 412 450 euros. Conclusions. The WICM is not cost-effective, and the costs per quality-adjusted life year are high. The costs of the integrated care intervention do not outweigh the limited effects on health-related quality of life after 12 months. More analyses of the cost-effectiveness of integrated care for community-dwelling frail elderly are recommended as well as consideration of the specific costs and effects. Key words: Cost-effectiveness, economic evaluation, frail elderly, general practice, integrated health care systems, prevention.
Introduction
known as frailty and is found to increase the risk of negative health
Due to population ageing, primary care systems throughout the world are encountering great challenges urging innovation in the organization of elderly care. Elderly individuals will gradually experience complex age-related problems in the physical, psychological, cognitive and social domains of daily functioning. This condition is
and social outcomes. Frailty is related to poor quality of life and
© The Author 2016. Published by Oxford University Press.
becoming more care dependent, with an increased likelihood of hospitalization and institutionalization (1). While budget cuts reduce health and social care expenditures, there is, thus, a strong need for providing high-quality care in order to maintain elderly’s quality of 154
This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact [email protected]
Cost-Effectiveness of the Walcheren Integrated Care Model life. It is frequently questioned whether the current approach to care delivery provides good value for money, given its fragmentation and its lack of responsiveness to the needs of frail elderly (2). Therefore, it is essential to consider alternatives. Integrated care has been increasingly advocated as a means to deliver value for money. Integrated care is defined as ‘a well-planned and well-organised set of services and care processes, targeted at multidimensional needs/problems of an individual client, or a category of persons with similar needs/problems’ (3). The two main features of integrated care are client centredness and continuity. First, integrated care is demand-oriented, addressing client’s needs by professionals from different disciplines and sectors (2). Second, integrated care aims to promote continuity: the set of services is delivered coherently, seamlessly and in accordance with clients’ changing needs over time (3). Common elements of integrated care models proven to be effective for communitydwelling frail elderly are a single entry point, geriatric assessments, case management, multidisciplinary teams (4), multidisciplinary protocols and discussions, web-based patient files and a network structure (5). Even though integrated care largely aims at cost-effectiveness, research comparing the associated costs and effects of interventions is scarce, limiting conclusions on the cost-effectiveness of integrated care interventions (6). Thus far, studies on cost-effectiveness have also shown mixed results. Some interventions for community-dwelling frail elderly have shown to be cost-effective compared with care as usual (6–9), whereas other studies have shown that integrated care is not cost-effective (10,11). The wide variation in the interventions, costs and effects considered in these studies, limits the possibility to draw conclusions regarding what promotes cost-effectiveness in integrated care for community-dwelling frail elderly. This study adds knowledge by exploring the cost-effectiveness of a specific integrated care intervention: the Walcheren Integrated Care Model (WICM). Our study is relevant for two reasons. In contrast to earlier studies that used a narrow health care perspective (6,7,9), we adopted a societal perspective, which is strongly recommended given its policy relevance at the macro level (12). Second, our intervention comprises all integrated care elements that have been identified as effective in prior research rather than a selection of elements. Therefore, we provide valuable insights regarding the cost-effectiveness of a comprehensive integrated care model for community-dwelling frail elderly. This study aimed to answer the following research question: Is the WICM cost-effective from a societal perspective after 12 months?
Methods Design The design of this study was quasi-experimental and included before and after measurements with a control group providing care as usual [for a more detailed description of the methods, see ref. (13)]. The cost-effectiveness analysis was conducted from a societal perspective and thus considered all costs related to the intervention, irrespective of who pays for these expenses (12).
155 using EASYcare, an evidence-based instrument used to assess care needs. A multidisciplinary treatment plan is then formulated in consultation with the elderly and their informal caregiver(s). Case management is provided by the nurse practitioner. Multidisciplinary meetings are attended by the GP, the nurse practitioner and other professionals, depending on the care required by the frail elderly. The entire process is supported by web-based patient files and multidisciplinary protocols. The WICM requires task reassignment and delegation between nurses and doctors, and among GPs, nursing home doctors and geriatricians. Consultations occur among primary, secondary and tertiary care providers. At the organizational level, a steering group serves as an umbrella organization under which the WICM is developed and disseminated. The steering group, which consists of representatives from all involved organizations, forms a Joint Governing Board that provides the necessary provider network. All patient representatives support the project, and the health insurer CZ provides financial support for the project. Compared with the WICM, care as usual in the Netherlands is fragmented and reactive. In the Dutch health care systems, patients need a referral from their GP to obtain care from the primary, secondary and tertiary echelons. GPs thus play the role of gatekeepers. Care as usual is fragmented, as professionals merely communicate bilaterally through referral letters and sporadic telephone calls. Moreover, care as usual is reactive; patients solely receive care for specific (health) problems on their own initiative. The GPs in the control group were unable to implement elements of the integrated model during the study period because they did not receive financial support from the health insurer to implement the integrated care activities of the WICM. Accordingly, participants in the control group were not systematically screened for frailty, their care needs were not assessed, multidisciplinary treatment plan were not formulated and case management was not provided. The GPs in the control group had a monodisciplinary focus; they did not organize multidisciplinary meetings or implement multidisciplinary protocols and web-based files. Furthermore, the GPs in the control group could not treat the frail elderly patients differently, as these GPs were not given information on who participated in the study. Therefore, the probability of bias was minimized.
Participants The study population consisted of the entire elderly patient population of the GPs in both the experimental and control groups (see Fig. 1). At baseline, 254 frail elderly from three GP practices were included in the experimental group, and 249 frail elderly from six GP practices in the control group. The frail elderly were asked whether they received informal care, including care from non-professionals and unpaid care provided by partners, family, close friends or neighbours. At baseline, 144 frail elderly in the experimental group reported receiving informal care compared with 118 frail elderly in the control group. After 12 months, the final study population included 184 frail elderly and 83 informal caregivers in the experimental group and 193 frail elderly and 76 informal caregivers in the control group.
Intervention In the WICM, the GP functions as care coordinator and as a partner in prevention. The GP practice is a single entry point for the elderly, their informal caregivers and health professionals. GPs detect frailty in their patient population using the Groningen Frailty Indicator, a validated 15-item instrument that measures decreases in physical, cognitive, social and psychological functioning. Elderly patients with a score of 4 or higher are visited by a nurse practitioner who assesses their functional, cognitive, mental and psychological functioning
Measures Effects The primary outcome of the intervention was quality of life, which was operationalized with health-related quality of life measured with the EQ-5D instrument. The EQ-5D has five dimensions: mobility, self-care, usual activities, pain/discomfort and anxiety/depression. Each dimension has three answering categories: (i) no problems; (ii) some problems and (iii) extreme problems. The answer to each of
Family Practice, 2016, Vol. 33, No. 2
156
Figure 1. Flow chart of selection and loss to follow-up of study participants in experimental and control groups
these 5 dimensions leads to a combination of 5 numbers and 243 possible health states (e.g. health state 21232 means: having some problems in walking about, having no problems with self-care; having some problems with performing usual activities; having extreme pain or discomfort; being moderately anxious or depressed). The health states unconscious and dead were added, which makes a total of 245 health states that were valued by the Dutch audience on their desirability. In previous research a general sample of the Dutch audience was asked to indicate what period of time in perfect health (11111) was equal to 10 years in a specific health state (e.g. 21232) (14). The weights obtained in this research were used to calculate the utility scores of the frail elderly of our study population. Measurements of these utility scores were obtained at baseline, 3 and 12 months and were used to calculate quality-adjusted life years (QALYs) for each respondent. QALYs combine both quantity and quality of life in one single measure; 1 QALY means 1 year in perfect health (14).
Costs Health care costs, intervention costs and informal care costs were calculated by multiplying the volume of care by its corresponding cost price. Health care volumes were collected through questionnaires and GP file research (see Table 1). In the questionnaires, the frail elderly were asked to indicate the volume of care in assisted living facilities and nursing homes, in day care centres and in home care. Information on the volume of care in assisted living facilities and nursing homes was sought retrospectively after 3 and 12 months. The volumes of day care and home care were measured in the questionnaire at baseline, 3 and 12 months. These volumes were extrapolated with a calculation rule to obtain the volume of care over 12 months. The volume at baseline was considered to be the volume for the first month, the volume at 3 months was considered the volume for the second and third months and the volume at
Cost-Effectiveness of the Walcheren Integrated Care Model
157
Table 1. Costs of care and data collection Type of care
Data collection Questionnaire
Health care costs GP practice GP Telephone consultation Consultation Consultation long Visit at home Visit at home long Practice assistant Telephone consultation Consultation Consultation long Visit at home Visit at home long Emergency GP Telephone consultation Consultation Visit at home Hospital Admission—general Admission—academic Outpatient clinic—general Outpatient clinic—academic Day surgery Emergency ward Ambulance Assisted living Temporary stay assisted living facility facility Nursing home Temporary stay nursing home Permanent stay nursing home Day treatment in nursing home Home care Home care—household activities Home care—personal care Home care—nursing care Day care centre Day care Paramedical Physiotherapy Occupational therapy Dietitian Psychosocial Psychological care Social care Intervention costs Preparation multidisciplinary meeting Multidisciplinary meeting Time spent per patient by case manager Informal care costs Household activities Personal care Instrumental tasks
Cost price GP file
Time registrations
Notes from multidisciplinary meeting
Number Number Number Number Number Number Number Number Number Number Number Number Number Days Days Number Number Number Number Number
€
14.51 29.02 58.04 44.57 89.13 5.48 10.97 21.93 16.84 33.68 21.29 42.58 63.88 450.85 595.95 66.33 133.70 260.15 156.50 271.55 93.28
Days Days Days Days Hours Hours Hours Days
246.67 246.67 146.66 24.87 45.60 67.37 26.00 37.31 22.80 27.98 89.83 67.37
Sessions Hours Hours Sessions Sessions Minutes
Minutes
Variablea
Minutes Minutes
Minutes
Variablea Variablea
Hours Hours Hours
24.87 45.60 13.00
The cost price differs per group health care professionals and is calculated for each group separately.
a
12 months was considered to be the volume for the last 9 months. The GP file research led to data regarding the volume of care within GP practices, hospitals and paramedical and psychological care. Data were not extrapolated, as the files provided the exact date of care consumption. Information on intervention costs was obtained from time registrations of the case managers and notes from the multidisciplinary meetings. The exact intervention time and therefore intervention costs could be calculated for each individual frail elderly person. The education costs of the GPs and case managers were not considered.
Informal care volumes were assessed by questionnaires completed by informal caregivers of the frail elderly at baseline, 3 and 12 months. The volume of informal care was measured using the Objective Burden of Informal Care Instrument (15) that distinguishes time spent on household, personal care and instrumental tasks. The same calculation rule was applied as for the health care costs assessed in the questionnaire of the frail elderly. Cost prices were determined using the Dutch guidelines of costing studies (16). Cost prices were determined in euros for the year 2011 and were corrected for inflation.
Family Practice, 2016, Vol. 33, No. 2
158
Statistical analysis The costs and the effects were compared by conducting a costeffectiveness analysis. First, the background characteristics of the experimental and control participants at baseline were compared by chi-square tests for the categorical variables and t-tests for the continuous variables. Second, the average volume of care and corresponding costs during the 12-month period were compared between the experimental and control groups with t-tests (17). The cost-effectiveness of the WICM was determined by calculating the incremental cost-effectiveness ratio (ICER). The ICER is calculated by dividing the difference between costs of the experimental group and control group (incremental costs) by the difference in effects between the experimental and control groups (incremental effects). Missing values were imputed with the fully conditional specification method. We determined the reliability of the ICER with the bootstrap method, which is a statistical method with repetitive computation to determine the confidence interval (CI) of the ICER. By sampling from both the distribution of costs and effects concurrently, multiple estimates from ICER were obtained (n = 10 000) (10).
Results The study population consisted of frail elderly patients with an average age of 82 years and an average score of 6 on the Groningen
Frailty Indicator (Table 2). Women were over-represented in both groups and the majority of the frail elderly lived alone and independently. Nearly half of the frail elderly patients had an informal caregiver. At baseline, the health-related quality of life was equal in both groups. Compared with the control group, the experimental group consisted of significantly more women and frail elderly who lived in assisted living facilities. Frail elderly patients most commonly used care from the GP, hospital and home care (Table 3). All experimental participants used GP care, as it was the single entry point of care for the intervention. In the control group, 4% of the frail elderly did not use any GP care over the 1-year period. Three-quarters of the frail elderly visited the hospital within 1 year. The highest expenses in both groups were for home care and informal care. Only limited differences were observed in the health care utilization of the experimental and control group. For two types of care, the cost differences were significant. The first type was GP care: the costs were significantly higher in the experimental group than in the control group. Furthermore, because the intervention costs were 0 in the control group, these costs were significantly higher in the experimental group. The average total costs in the experimental group were 17,089 euros for each frail elderly person over a 1-year period (Table 4). The costs were lower in the control group, with an average of 15,189 euros for each frail elderly person. The dispersion of costs was high:
Table 2. Characteristics of the study participants in experimental and control groups at baseline
Groningen Frailty Indicator (0–15) Age Sex—women Marital status Married and living together Single and widowed Living situation Independently Assisted living facility Informal caregiver Health-related quality of life (0–1)
Experimental group (n = 184)
Control group (n = 193)
T-statistic or chi square
6.0 (2.0) 81.8 (4.7) 70%
5.8 (1.8) 82.3 (5.3) 60%
−1.3 0.8 4.1* 0.9
37% 63%
42% 58%
72% 28% 45% 0.65 (0.2)
82% 18% 39% 0.67 (0.3)
6.1*
1.5 0.5
*P
Health Service Research
Cost-effectiveness of the ‘Walcheren Integrated Care Model’ intervention for community-dwelling frail elderly Wilhelmina M Looman*, Robbert Huijsman, Clazien A M Bouwmans-Frijters, Elly A Stolk and Isabelle N Fabbricotti Institute of Health Policy and Management, Erasmus University Rotterdam, Rotterdam, The Netherlands. *Correspondence to Wilhelmina M Looman, Institute of Health Policy and Management, Erasmus University Rotterdam, PO Box 1738, 3000 DR Rotterdam, The Netherlands; E-mail: [email protected]
Abstract Background. An important aim of integrated care for frail elderly is to generate more costeffective health care. However, empirical research on the cost-effectiveness of integrated care for community-dwelling frail elderly is limited. Objective. This study reports on the cost-effectiveness of the Walcheren Integrated Care Model (WICM) after 12 months from a societal perspective. Methods. The design of this study was quasi-experimental. In total, 184 frail elderly patients from 3 GP practices that implemented the WICM were compared with 193 frail elderly patients of 5 GP practices that provided care as usual. Effects were determined by health-related quality of life (EQ5D questionnaire). Costs were assessed based on questionnaires, GP files, time registrations and reports from multidisciplinary meetings. Average costs and effects were compared using t-tests. The incremental cost-effectiveness ratio (ICER) was calculated, and bootstrap methods were used to determine its reliability. Results. Neither the WICM nor care as usual resulted in a change in health-related quality of life.The average total costs of the WICM were higher than care as usual (17 089 euros versus 15 189 euros). The incremental effects were 0.00, whereas the incremental costs were 1970 euros, indicating an ICER of 412 450 euros. Conclusions. The WICM is not cost-effective, and the costs per quality-adjusted life year are high. The costs of the integrated care intervention do not outweigh the limited effects on health-related quality of life after 12 months. More analyses of the cost-effectiveness of integrated care for community-dwelling frail elderly are recommended as well as consideration of the specific costs and effects. Key words: Cost-effectiveness, economic evaluation, frail elderly, general practice, integrated health care systems, prevention.
Introduction
known as frailty and is found to increase the risk of negative health
Due to population ageing, primary care systems throughout the world are encountering great challenges urging innovation in the organization of elderly care. Elderly individuals will gradually experience complex age-related problems in the physical, psychological, cognitive and social domains of daily functioning. This condition is
and social outcomes. Frailty is related to poor quality of life and
© The Author 2016. Published by Oxford University Press.
becoming more care dependent, with an increased likelihood of hospitalization and institutionalization (1). While budget cuts reduce health and social care expenditures, there is, thus, a strong need for providing high-quality care in order to maintain elderly’s quality of 154
This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact [email protected]
Cost-Effectiveness of the Walcheren Integrated Care Model life. It is frequently questioned whether the current approach to care delivery provides good value for money, given its fragmentation and its lack of responsiveness to the needs of frail elderly (2). Therefore, it is essential to consider alternatives. Integrated care has been increasingly advocated as a means to deliver value for money. Integrated care is defined as ‘a well-planned and well-organised set of services and care processes, targeted at multidimensional needs/problems of an individual client, or a category of persons with similar needs/problems’ (3). The two main features of integrated care are client centredness and continuity. First, integrated care is demand-oriented, addressing client’s needs by professionals from different disciplines and sectors (2). Second, integrated care aims to promote continuity: the set of services is delivered coherently, seamlessly and in accordance with clients’ changing needs over time (3). Common elements of integrated care models proven to be effective for communitydwelling frail elderly are a single entry point, geriatric assessments, case management, multidisciplinary teams (4), multidisciplinary protocols and discussions, web-based patient files and a network structure (5). Even though integrated care largely aims at cost-effectiveness, research comparing the associated costs and effects of interventions is scarce, limiting conclusions on the cost-effectiveness of integrated care interventions (6). Thus far, studies on cost-effectiveness have also shown mixed results. Some interventions for community-dwelling frail elderly have shown to be cost-effective compared with care as usual (6–9), whereas other studies have shown that integrated care is not cost-effective (10,11). The wide variation in the interventions, costs and effects considered in these studies, limits the possibility to draw conclusions regarding what promotes cost-effectiveness in integrated care for community-dwelling frail elderly. This study adds knowledge by exploring the cost-effectiveness of a specific integrated care intervention: the Walcheren Integrated Care Model (WICM). Our study is relevant for two reasons. In contrast to earlier studies that used a narrow health care perspective (6,7,9), we adopted a societal perspective, which is strongly recommended given its policy relevance at the macro level (12). Second, our intervention comprises all integrated care elements that have been identified as effective in prior research rather than a selection of elements. Therefore, we provide valuable insights regarding the cost-effectiveness of a comprehensive integrated care model for community-dwelling frail elderly. This study aimed to answer the following research question: Is the WICM cost-effective from a societal perspective after 12 months?
Methods Design The design of this study was quasi-experimental and included before and after measurements with a control group providing care as usual [for a more detailed description of the methods, see ref. (13)]. The cost-effectiveness analysis was conducted from a societal perspective and thus considered all costs related to the intervention, irrespective of who pays for these expenses (12).
155 using EASYcare, an evidence-based instrument used to assess care needs. A multidisciplinary treatment plan is then formulated in consultation with the elderly and their informal caregiver(s). Case management is provided by the nurse practitioner. Multidisciplinary meetings are attended by the GP, the nurse practitioner and other professionals, depending on the care required by the frail elderly. The entire process is supported by web-based patient files and multidisciplinary protocols. The WICM requires task reassignment and delegation between nurses and doctors, and among GPs, nursing home doctors and geriatricians. Consultations occur among primary, secondary and tertiary care providers. At the organizational level, a steering group serves as an umbrella organization under which the WICM is developed and disseminated. The steering group, which consists of representatives from all involved organizations, forms a Joint Governing Board that provides the necessary provider network. All patient representatives support the project, and the health insurer CZ provides financial support for the project. Compared with the WICM, care as usual in the Netherlands is fragmented and reactive. In the Dutch health care systems, patients need a referral from their GP to obtain care from the primary, secondary and tertiary echelons. GPs thus play the role of gatekeepers. Care as usual is fragmented, as professionals merely communicate bilaterally through referral letters and sporadic telephone calls. Moreover, care as usual is reactive; patients solely receive care for specific (health) problems on their own initiative. The GPs in the control group were unable to implement elements of the integrated model during the study period because they did not receive financial support from the health insurer to implement the integrated care activities of the WICM. Accordingly, participants in the control group were not systematically screened for frailty, their care needs were not assessed, multidisciplinary treatment plan were not formulated and case management was not provided. The GPs in the control group had a monodisciplinary focus; they did not organize multidisciplinary meetings or implement multidisciplinary protocols and web-based files. Furthermore, the GPs in the control group could not treat the frail elderly patients differently, as these GPs were not given information on who participated in the study. Therefore, the probability of bias was minimized.
Participants The study population consisted of the entire elderly patient population of the GPs in both the experimental and control groups (see Fig. 1). At baseline, 254 frail elderly from three GP practices were included in the experimental group, and 249 frail elderly from six GP practices in the control group. The frail elderly were asked whether they received informal care, including care from non-professionals and unpaid care provided by partners, family, close friends or neighbours. At baseline, 144 frail elderly in the experimental group reported receiving informal care compared with 118 frail elderly in the control group. After 12 months, the final study population included 184 frail elderly and 83 informal caregivers in the experimental group and 193 frail elderly and 76 informal caregivers in the control group.
Intervention In the WICM, the GP functions as care coordinator and as a partner in prevention. The GP practice is a single entry point for the elderly, their informal caregivers and health professionals. GPs detect frailty in their patient population using the Groningen Frailty Indicator, a validated 15-item instrument that measures decreases in physical, cognitive, social and psychological functioning. Elderly patients with a score of 4 or higher are visited by a nurse practitioner who assesses their functional, cognitive, mental and psychological functioning
Measures Effects The primary outcome of the intervention was quality of life, which was operationalized with health-related quality of life measured with the EQ-5D instrument. The EQ-5D has five dimensions: mobility, self-care, usual activities, pain/discomfort and anxiety/depression. Each dimension has three answering categories: (i) no problems; (ii) some problems and (iii) extreme problems. The answer to each of
Family Practice, 2016, Vol. 33, No. 2
156
Figure 1. Flow chart of selection and loss to follow-up of study participants in experimental and control groups
these 5 dimensions leads to a combination of 5 numbers and 243 possible health states (e.g. health state 21232 means: having some problems in walking about, having no problems with self-care; having some problems with performing usual activities; having extreme pain or discomfort; being moderately anxious or depressed). The health states unconscious and dead were added, which makes a total of 245 health states that were valued by the Dutch audience on their desirability. In previous research a general sample of the Dutch audience was asked to indicate what period of time in perfect health (11111) was equal to 10 years in a specific health state (e.g. 21232) (14). The weights obtained in this research were used to calculate the utility scores of the frail elderly of our study population. Measurements of these utility scores were obtained at baseline, 3 and 12 months and were used to calculate quality-adjusted life years (QALYs) for each respondent. QALYs combine both quantity and quality of life in one single measure; 1 QALY means 1 year in perfect health (14).
Costs Health care costs, intervention costs and informal care costs were calculated by multiplying the volume of care by its corresponding cost price. Health care volumes were collected through questionnaires and GP file research (see Table 1). In the questionnaires, the frail elderly were asked to indicate the volume of care in assisted living facilities and nursing homes, in day care centres and in home care. Information on the volume of care in assisted living facilities and nursing homes was sought retrospectively after 3 and 12 months. The volumes of day care and home care were measured in the questionnaire at baseline, 3 and 12 months. These volumes were extrapolated with a calculation rule to obtain the volume of care over 12 months. The volume at baseline was considered to be the volume for the first month, the volume at 3 months was considered the volume for the second and third months and the volume at
Cost-Effectiveness of the Walcheren Integrated Care Model
157
Table 1. Costs of care and data collection Type of care
Data collection Questionnaire
Health care costs GP practice GP Telephone consultation Consultation Consultation long Visit at home Visit at home long Practice assistant Telephone consultation Consultation Consultation long Visit at home Visit at home long Emergency GP Telephone consultation Consultation Visit at home Hospital Admission—general Admission—academic Outpatient clinic—general Outpatient clinic—academic Day surgery Emergency ward Ambulance Assisted living Temporary stay assisted living facility facility Nursing home Temporary stay nursing home Permanent stay nursing home Day treatment in nursing home Home care Home care—household activities Home care—personal care Home care—nursing care Day care centre Day care Paramedical Physiotherapy Occupational therapy Dietitian Psychosocial Psychological care Social care Intervention costs Preparation multidisciplinary meeting Multidisciplinary meeting Time spent per patient by case manager Informal care costs Household activities Personal care Instrumental tasks
Cost price GP file
Time registrations
Notes from multidisciplinary meeting
Number Number Number Number Number Number Number Number Number Number Number Number Number Days Days Number Number Number Number Number
€
14.51 29.02 58.04 44.57 89.13 5.48 10.97 21.93 16.84 33.68 21.29 42.58 63.88 450.85 595.95 66.33 133.70 260.15 156.50 271.55 93.28
Days Days Days Days Hours Hours Hours Days
246.67 246.67 146.66 24.87 45.60 67.37 26.00 37.31 22.80 27.98 89.83 67.37
Sessions Hours Hours Sessions Sessions Minutes
Minutes
Variablea
Minutes Minutes
Minutes
Variablea Variablea
Hours Hours Hours
24.87 45.60 13.00
The cost price differs per group health care professionals and is calculated for each group separately.
a
12 months was considered to be the volume for the last 9 months. The GP file research led to data regarding the volume of care within GP practices, hospitals and paramedical and psychological care. Data were not extrapolated, as the files provided the exact date of care consumption. Information on intervention costs was obtained from time registrations of the case managers and notes from the multidisciplinary meetings. The exact intervention time and therefore intervention costs could be calculated for each individual frail elderly person. The education costs of the GPs and case managers were not considered.
Informal care volumes were assessed by questionnaires completed by informal caregivers of the frail elderly at baseline, 3 and 12 months. The volume of informal care was measured using the Objective Burden of Informal Care Instrument (15) that distinguishes time spent on household, personal care and instrumental tasks. The same calculation rule was applied as for the health care costs assessed in the questionnaire of the frail elderly. Cost prices were determined using the Dutch guidelines of costing studies (16). Cost prices were determined in euros for the year 2011 and were corrected for inflation.
Family Practice, 2016, Vol. 33, No. 2
158
Statistical analysis The costs and the effects were compared by conducting a costeffectiveness analysis. First, the background characteristics of the experimental and control participants at baseline were compared by chi-square tests for the categorical variables and t-tests for the continuous variables. Second, the average volume of care and corresponding costs during the 12-month period were compared between the experimental and control groups with t-tests (17). The cost-effectiveness of the WICM was determined by calculating the incremental cost-effectiveness ratio (ICER). The ICER is calculated by dividing the difference between costs of the experimental group and control group (incremental costs) by the difference in effects between the experimental and control groups (incremental effects). Missing values were imputed with the fully conditional specification method. We determined the reliability of the ICER with the bootstrap method, which is a statistical method with repetitive computation to determine the confidence interval (CI) of the ICER. By sampling from both the distribution of costs and effects concurrently, multiple estimates from ICER were obtained (n = 10 000) (10).
Results The study population consisted of frail elderly patients with an average age of 82 years and an average score of 6 on the Groningen
Frailty Indicator (Table 2). Women were over-represented in both groups and the majority of the frail elderly lived alone and independently. Nearly half of the frail elderly patients had an informal caregiver. At baseline, the health-related quality of life was equal in both groups. Compared with the control group, the experimental group consisted of significantly more women and frail elderly who lived in assisted living facilities. Frail elderly patients most commonly used care from the GP, hospital and home care (Table 3). All experimental participants used GP care, as it was the single entry point of care for the intervention. In the control group, 4% of the frail elderly did not use any GP care over the 1-year period. Three-quarters of the frail elderly visited the hospital within 1 year. The highest expenses in both groups were for home care and informal care. Only limited differences were observed in the health care utilization of the experimental and control group. For two types of care, the cost differences were significant. The first type was GP care: the costs were significantly higher in the experimental group than in the control group. Furthermore, because the intervention costs were 0 in the control group, these costs were significantly higher in the experimental group. The average total costs in the experimental group were 17,089 euros for each frail elderly person over a 1-year period (Table 4). The costs were lower in the control group, with an average of 15,189 euros for each frail elderly person. The dispersion of costs was high:
Table 2. Characteristics of the study participants in experimental and control groups at baseline
Groningen Frailty Indicator (0–15) Age Sex—women Marital status Married and living together Single and widowed Living situation Independently Assisted living facility Informal caregiver Health-related quality of life (0–1)
Experimental group (n = 184)
Control group (n = 193)
T-statistic or chi square
6.0 (2.0) 81.8 (4.7) 70%
5.8 (1.8) 82.3 (5.3) 60%
−1.3 0.8 4.1* 0.9
37% 63%
42% 58%
72% 28% 45% 0.65 (0.2)
82% 18% 39% 0.67 (0.3)
6.1*
1.5 0.5
*P
